Please download the pdf below and fax to 480.304.3036 or secure email to email@example.com. Clinical documentation must be attached in order for the prior authorization request to be processed.
FOR INPATIENT EMERGENCY ROOM AUTHORIZATION YOU MUST CALL 877.587.2700, AVAILABLE 24/7.
FAILURE TO PROVIDE SUFFICIENT CLINICAL INFORMATION OR FAILURE TO COMPLETE THE AUTHORIZATION FORM WILL RESULT IN A DELAY, A DENIAL OR THE NON-PROCESSING OF YOUR REQUEST.
1. Authorizations should be submitted prior to the scheduling of a procedure or at a minimum; five (5) business days prior to the scheduled procedure to facilitate the required medical review. Failure to submit requests in a timely manner does not warrant an urgent or STAT authorization review request.
2. STAT authorizations are reserved for true, same day medical emergencies. These authorizations will be valid for the date of issue only and cannot be updated, changed or altered in any manner.
3. The form should be completed in its entirety including complete addresses, phone numbers with extensions, current fax numbers, CPT/HCPCs codes, ICD10, Units and all NPI and Tax ID numbers. Incomplete forms or forms received without clinical documentation or physician orders will be returned as un-processable.
4. A fax cover page with direct contact information i.e. phone numbers (please include your extension) and fax numbers is encouraged.
5. Prior to calling for status of an authorization please verify that it has not been received via fax.